Even though we all dread writing them, veterinary records are some of the most important parts of our job as veterinarians. These records allow us to monitor disease over time in patients we see more than once. They also allow us to remind ourselves of each patient’s particular comfort level with a veterinary exam to make sure they are comfortable every time they come to see us. Lastly, they help us to send reminders for appointments or rechecks in the future and to communicate with referring clinics if one of our patients ever needs specialty care.
These records are the way we keep track of our patients, but as a student, writing them can be a daunting task. When writing these we include all diagnostic tests, diagnoses, and plans for the client and the pet going home. In this sense, we are the last word for that patient when their owner needs to know how to proceed. This can be scary while still in training, but, of course, in a teaching hospital, all of these written records are approved by our senior clinicians before they are sent home with our clients. It is also a fantastic way for us, as students, to not only learn how to keep a good medical record but to summarize our cases and learn about disease processes and veterinary problems by writing it down in a very concrete format to refer to later. So, even though paperwork takes time and can be tedious, it is a great benefit to our animals and our education to be able to do it well!